Today's Anesthesia Consult

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Noyac

Noyac

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70 yo obese (120kg) male with schizophrenia, 4pk/day smoking history times 40yrs, ex-miner without respiratory precautions, and HTN. HE is scheduled for a colectomy secondary to recurrent polyp which has changed color but is not yet cancer per GI. Airway is a Gr III with large full beard as well. Sitting in the pre-op clinic he is SOB and has to take a couple big breaths before answering questions. He has been sitting for an hour. Work up includes PFT's which show severe COPD and restrictive pattern without much improvement with bronchodilators. Lexical Stress Echo, starting HR 97 achieved 111bpm during study. No ischemia, mild hypokinesis, EF45% no CP. He lives an extremely sedentary lifestyle. H/H = 19/57, Na 132, K 4.8, Cl 96, CO2 29. ABG=7.34/47/45/26/77% on RA.

What's your plan?
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Noyac said:
What's your plan?
Click to expand...

First I'd like to figure out how he got to weigh 120 kg while smoking 4 packs a day. The sheer time involved in smoking 80 cigarettes in a day combined with the boost to your metabolic rate should make you fairly damn skinny. I mean to maintain 120 kg you'd have to spend every second you are awake with either a cigarette or food in your mouth. That's a lot of work.
 
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Send him home. The COPD will kill him long before the non-cancerous colon polyp.
 
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I'm leaning in @SaltyDog direction...this patient isn't an OR problem but he'll definitely be a post-op vent dependent problem
 
On a serious note, He is not a surgical candidate at this time and the best he can do is go home, quit smoking, go on home O2, and lose weight with a follow up colonoscopy in 2-3 months.
At that time if he makes progress then the surgery can be considered, maybe with a CSE as the main anesthetic, but if he can not quit smoking or lose weight there is no point to this surgery.
 
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How is this guy 70?

Airway is my biggest concern. Describing a guy I'd doubt you could easily ventilate + low reserve after induction. As long as the rest of his intubation criteria is okay, I'd opt for video laryngoscopy with fiberoptic and LMA and other intubating accessories there. If rest of airway exam is poor, would opt for awake fiberoptic with good topicalization and minimal sedation.

Intraop: No real concerns except as above, extubation sounds like a nightmare.
 
They don't let you cancel pointless surgeries on the oral boards, so I'll play. However, in real life this is an elective surgery and borderline unnecessary.

This guy has severe pulmonary fibrosis with a significant A-a gradient and won't be alive much longer due to his pulmonary disease...especially if he is still smoking like that.

He has the potential to be a difficult airway based on the given information, but he may not tolerate awake intubation either because of his schizophrenia. He also won't tolerate long periods of apnea due to the obesity and pulmonary fibrosis. I would do an inhalation induction, keep him spontaneously breathing and go straight to the glidescope...again, assuming nothing else too scary about the airway. I would place a couple IVs and an a-line for ABGs. Patients with severe lung disease do better when kept on the drier side, so I would use a pulse pressure variation monitor to guide fluid management. I would use a low tidal volume ventilation strategy. If the patient were agreeable to it and no contraindications, I would also consider placing an epidural pre-op for post-op pain control. This patient will not tolerate atelectasis or respiratory depression postoperatively. I would have an extremely low threshold to keep the patient intubated. It's possible this patient will require prolonged post-op mechanical ventilation. He or his caretaker needs to be aware of the likelihood of spending a long time on the vent and that he may not survive his post-op course
 
His O2 sat is 77% and he's not on home O2? Or is it just not mentioned? I bet his pulm BP is pretty high if he lives with 77% O2 saturation.

I would tell him he is at high risk of developing post op respiratory failure that may require prolonged intubation and possibly death and he should really consider the need for the surgery. Like Salty said.

If the case is to proceed after all that, my plan would be preop a-line, epidural for anesthesia, provided there is no contraindication to neuraxial anesthesia.

If there is contraindication, then propofol, sux, glidescooe, tube
 
If it's "gotta go" then prop, sux, tube, LTAC.
 
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A resident here but going to take a shot at it:
Could he be optimized in certain ways possible i.e wait for a few weeks with the following(if the cancerous risk is permissible)
Weight loss
Pulmonary status optimization: steroids, bronchodilators,chest physiotherapy ,smoking cessation
What does his right heart function look like? It seems certain he would have mod-severe pul HTN so perhaps need a right heart cath. If severe, maybe admit to ICU the previous day and optimize with pul vasodilators.
Plan: epidural, a line with PPV monitoring , GA with ETT (awake vs asleep depending on the airway )
Extubate to NIV
 
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Obese with mp3 is not necesarily a difficult airway as long as mouth opening is adequate. We intubate these with prop sux glidescope all the time. Beard may make ventilation difficult, nothing an LMA or two person bag mask with oral airway cant handle.

His airway is the least of your problem.
 
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sevodex1 said:
A resident here but going to take a shot at it:
Could he be optimized in certain ways possible i.e wait for a few weeks with the following(if the cancerous risk is permissible)
Weight loss
Pulmonary status optimization: steroids, bronchodilators,chest physiotherapy ,smoking cessation
What does his right heart function look like? It seems certain he would have mod-severe pul HTN so perhaps need a right heart cath. If severe, maybe admit to ICU the previous day and optimize with pul vasodilators.
Plan: epidural, a line with PPV monitoring , GA with ETT (awake vs asleep depending on the airway )
Extubate to NIV
Click to expand...
Why do you want to intubate him if he has a functioning epidural???
This is going to be a limited colectomy and should take less than one hour in the hands of a reasonable surgeon.
 
Planktonmd said:
Why do you want to intubate him if he has a functioning epidural???
This is going to be a limited colectomy and should take less than one hour in the hands of a reasonable surgeon.
Click to expand...
If it was laparoscopic
 
Planktonmd said:
Why do you want to intubate him if he has a functioning epidural???
This is going to be a limited colectomy and should take less than one hour in the hands of a reasonable surgeon.
Click to expand...

a functioning epidural is rarely good enough as a primary anesthetic for a bowel resection. Probably requires quite a bit of sedation on top of it to make it even remotely tolerable. And this guy barely breathes when he is wide awake and sitting upright. Sedated and supine with his belly open? Not a chance IMHO.
 
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Mman said:
a functioning epidural is rarely good enough as a primary anesthetic for a bowel resection. Probably requires quite a bit of sedation on top of it to make it even remotely tolerable. And this guy barely breathes when he is wide awake and sitting upright. Sedated and supine with his belly open? Not a chance IMHO.
Click to expand...
CSE would be ideal but a good epidural will work too. You need a surgeon who understands and does not ask for perfect muscle relaxation.
 
how long is the surgery?
lap or open?
can he tolerate lying flat?
how bad is his schizo? can he tolerate being awake with some precedex for the duration of the procedure?
 
Planktonmd said:
CSE would be ideal but a good epidural will work too. You need a surgeon who understands and does not ask for perfect muscle relaxation.
Click to expand...

Sorry, but I REALLY don't want to sit there and babysit/handhold a schizophrenic who now has an open belly and is strapped to an OR table. Recipe for disaster at worst, certainly a huge PITA where you will tempted to over-sedate, and just moderately entertaining at best.
 
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Planktonmd said:
CSE would be ideal but a good epidural will work too. You need a surgeon who understands and does not ask for perfect muscle relaxation.
Click to expand...

I think this is a reasonable option with the right patient and right surgeon. I'm not convinced this is the right patient. Are we sure this patient with schizophrenia is going to be able to lie still and tolerate being awake? Dealing with this guy's airway emergently is not ideal and you're going to be struggling with apnea as you have to give him increasing doses of sedation. Tube him now and have an ICU bed with a vent ready for him postop.
 
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Why is an epidural okay for c section but not okay for colon resection? Sure, the level may need to be a little higher and patients may have a little more discomfort, but ketamine or precedex can help with that.
 
is that stress test suboptimal? I'll have to look this up real quick....

off the top of my head...85% or so of predicted max? 220-70 x .85 is around 125, pharmacological stress?
 
Might even consider telling him to shave. I dont know why I don't do this now but when this guys come in looking like my AVI, I really want to ask them, "The beard or your life." I get that I have RSI and sux and all sorts of things in my arsenal, but at least give me a chance to ventilate you.
 
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Chloroform4Life said:
Obese with mp3 is not necesarily a difficult airway as long as mouth opening is adequate. We intubate these with prop sux glidescope all the time. Beard may make ventilation difficult, nothing an LMA or two person bag mask with oral airway cant handle.

His airway is the least of your problem.
Click to expand...
Exactly this.....the glidescope is the reason anesthesia has gotten easy. i haven't reach for a fiberoptic in forever (famous last words)
 
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if he can tolerate lying flat and being co-operative during procedure...and we absolutely have to do this...

i'll assume he has pulm HTN, i'll check out the RV function on the stress echo, I'll assume he has CAD despite the stress test

18g IV, epidural, aline, titrate epidural 5 ml at a time with some push dose pressors around (in case his RV/PA HTN can't tolerate a large bolus)

precedex for sedation... (no midaz/fent - I don't need his CO2 rising and making the PAP any worse, no ketamine - don't want to set of any craziness in this guy)

black mask strap on PSV (make shift bipap if he needs it to tolerate lying flat)

second IV

minimize the fluid and don't let his BP drop >20% of baseline (keep his coronaries flowing), check an occaisional abg for lytes/CO2 since we already have it

leave epidural catheter in post op for pain control
 
Chloroform4Life said:
Why is an epidural okay for c section but not okay for colon resection? Sure, the level may need to be a little higher and patients may have a little more discomfort, but ketamine or precedex can help with that.
Click to expand...
I'm no genius, but I'd be it has something to do with referred pain. If you think about it, why were appy, prostates, and many other belly surgeries never done under regional. Probably timing, probably referred pain, probably incomplete blocks, etc, etc, etc.... as said about though, this is probably not the guy to do a regional with sedation
 
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surgeon 100% demands muscle relaxant, patient can't tolerate lying flat or demands to be asleep and I absolutely have to do GA....

i'll bite and go with the awake fiberoptic (argument is maybe a difficult vent and difficult tube in a guy with LITTLE reserve, if he goes down, he goes down hard)

downside I think to AFIO in this is the schizo and possible HTN/tachy increasing O2 demand

somewhat co-operative....good counseling and assurance and hand holding....18 g IV, glyco .4 , start dex infusion .7, epidural, inhaled 4% lido while aline goes in, paint tonsillar pillars with viscous lido, 5-7 cc 2% lido to get check epidural, AFOI (spray cords with 4% lido , back out, wait a min, do it again), ketamine bolus as back up if he is freaking out, esmolol/nitroG dilute bolus to keep him from having MI if he does freak out, once tube in 20-30 prop and some sevo

intraop:
start titrating up the epidural with 2% lido so surgeon can start up, start my epidural infusion, sevo (no nitrous - pA htn, no dez - irritate) , Pressure control, minimize Fio2, peep 6-7, peak/plateau pressures will probably be a littler higher is really restrictive disease, don't let him breath-stack, adjust IE ratio, minimize fluids, avoid hypotension/tachycardia, don't give too much rock and check his twitches, check an abg every once in a while, heck maybe a BIS just to minimize his anesthetic (if schizo is a risk factor for post op delerium)

emergence: get this guy breathing early on PSV, make sure he is reversed (we have sugammadex now which is cool), if everything looks good (uncomplicated procedure, minimal fluid, no BP issues, good volumes, minimal suport, good abg) I would try to extubate (head up position, maybe even right to bipap) in a controlled environment with some backup tools around (fiber optic , glide, maybe even an extra hand around)

i'm sure I just opened myself up to tons of critique and pimp questions but its fun...
 
Agree with several above. This guy is FUBAR. The big question is what will kill him first? The surgery or the COPD? Either one will make the other that much worse. The problem with this guy is even if you monitor the polyp to see it's progression to delay surgery, do you really think a 70yo obese, schizo, COPDer is going to get optimized if you delay this surgery? It's not like he's going to all of a sudden smarten up, put down the cigs and start running laps and come back 6 months from now needing the surgery so he can get his colostomy so he can continue training for his Iron Man Competition...

You talk to the patient (family depending on his level of schizophrenia) and the surgeon and you give a good detailed explanation of the HIGH risk of the surgery under his condition, the TERRIBLE post-op recovery and high likelihood of post-op vent, trach and LTAC. Determine if the risks of these are worth it, or would he rather risk the cancer growing and attempting to "enjoy" however long he lives.

All that being said, if I HAD to do this case, assuming his cardiac status is what was presented, I think a CSE would be a good choice. He doesn't have severe AS or ischemia, so I'd place one after doing a pre-op A-line. Airway is whatever... I'd evaluate it and determine if I thought it would be a simple DL vs. all those fancy toys we have. A couple large IVs. No central line (at this point... although when it all goes to heck he can get one or later in the ICU when he's on every pressor...). Extubation? LOL... good luck with that. I'll just wait until I get assigned to his trach later the following week before I even think about that ETT again.
 
Chloroform4Life said:
Why is an epidural okay for c section but not okay for colon resection? Sure, the level may need to be a little higher and patients may have a little more discomfort, but ketamine or precedex can help with that.
Click to expand...

how deep are you willing to sedate a guy with a room air sat of 77%?

What's wrong with putting an endotracheal tube in him? This guy is not going to do well. My anesthetic isn't going to fix him. He gets a tube and an ICU bed on a vent postop. If he ends up getting trached, well that's on him not taking care of himself for the last 50 years.
 
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Twiggidy said:
I'm no genius, but I'd be it has something to do with referred pain. If you think about it, why were appy, prostates, and many other belly surgeries never done under regional. Probably timing, probably referred pain, probably incomplete blocks, etc, etc, etc.... as said about though, this is probably not the guy to do a regional with sedation
Click to expand...
Where did you get that information from???
All these surgeries you mentioned can be done very successfully under neuraxial anesthesia!
 
Planktonmd said:
Where did you get that information from???
All these surgeries you mentioned can be done very successfully under neuraxial anesthesia!
Click to expand...
Can sure.....part of normal resident eductation? did zero of most of these. they barely let us do hernias under spinal. slow surgeons and i guess were were slow residents. it was always, "throw in an LMA and lets go" i guess i was trained super conservatively....i take the prostate quote back. i didn't do many personally but i remember in residency many prostates being done with spinal...if i say the spinal drug i may give away my identity (or a least where i trained lol)
 
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The reason belly cases are miserable under regional are 1) lack of vagus suppression and 2) lack of diaphragmatic coverage. Thus even the best epidural/spinal can have a nauseated pt with referred pain (sound familiar from those c-sections?). We tolerate this in OB so people can see their babies but it's otherwise a crappy anesthetic. Granted in a colectomy the surgeons would be further from the diaphragm and could theoretically avoid pulling the bowel too much.

I personally wouldn't want to screw around sedating this guy and would intubate at the start.
 
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sigrhoillusion said:
Agree with several above. This guy is FUBAR. The big question is what will kill him first? The surgery or the COPD? Either one will make the other that much worse. The problem with this guy is even if you monitor the polyp to see it's progression to delay surgery, do you really think a 70yo obese, schizo, COPDer is going to get optimized if you delay this surgery? It's not like he's going to all of a sudden smarten up, put down the cigs and start running laps and come back 6 months from now needing the surgery so he can get his colostomy so he can continue training for his Iron Man Competition...

You talk to the patient (family depending on his level of schizophrenia) and the surgeon and you give a good detailed explanation of the HIGH risk of the surgery under his condition, the TERRIBLE post-op recovery and high likelihood of post-op vent, trach and LTAC. Determine if the risks of these are worth it, or would he rather risk the cancer growing and attempting to "enjoy" however long he lives.

All that being said, if I HAD to do this case, assuming his cardiac status is what was presented, I think a CSE would be a good choice. He doesn't have severe AS or ischemia, so I'd place one after doing a pre-op A-line. Airway is whatever... I'd evaluate it and determine if I thought it would be a simple DL vs. all those fancy toys we have. A couple large IVs. No central line (at this point... although when it all goes to heck he can get one or later in the ICU when he's on every pressor...). Extubation? LOL... good luck with that. I'll just wait until I get assigned to his trach later the following week before I even think about that ETT again.
Click to expand...

Agree, high likelihood he needs vent post op....

But just just to play devils advocate, if you have no narcs on, epidural is working, fully reversed, case was quick, minimal fluids, abg is fine, intubation was smooth.....why not at least see how he does on psv? I guess the atelectasis from inhalational gas is there...but Is he going to be any better in 24 hrs snowed on the vent over night so the sicu nurses don't have to deal with him?

All I'm getting at is that many people get left intubated and sent to the sicu that could have been extubated in the OR...some of those end up with VAP, some of those get tons of benzos and more narcs for sedation and have illeus and post op delirium.....I'm not sure that being on a vent is Doing him any good

Would any of you guys trial him on Psv or extubate to bipap if all looked well?
 
Noyac said:
70 yo obese (120kg) male with schizophrenia, 4pk/day smoking history times 40yrs, ex-miner without respiratory precautions, and HTN. HE is scheduled for a colectomy secondary to recurrent polyp which has changed color but is not yet cancer per GI. Airway is a Gr III with large full beard as well. Sitting in the pre-op clinic he is SOB and has to take a couple big breaths before answering questions. He has been sitting for an hour. Work up includes PFT's which show severe COPD and restrictive pattern without much improvement with bronchodilators. Lexical Stress Echo, starting HR 97 achieved 111bpm during study. No ischemia, mild hypokinesis, EF45% no CP. He lives an extremely sedentary lifestyle. H/H = 19/57, Na 132, K 4.8, Cl 96, CO2 29. ABG=7.34/47/45/26/77% on RA.

What's your plan?
Click to expand...
I do half a dozen of these every week. Prop/Sux/McGrath/Tube...next!
 
I'd tell the surgeon to go back on his meds. This is elective surgery for a possible cancer risk reduction on a patient that will likely be dead soon from his pulmonary disease. He's as delusional as the patient.
No need to kill him today.


--
Il Destriero
 
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Planktonmd said:
Why do you want to intubate him if he has a functioning epidural???
This is going to be a limited colectomy and should take less than one hour in the hands of a reasonable surgeon.
Click to expand...

To control the airway on a guy that is 77 mm Hg on RA. My guess is he falls down the steep curve when supine and someone is forcefully pushing his guts up into his diaphragm. Throw in whatever you want to give him for anxiolysis and we're probably making this much more difficult on ourselves than it has to be.

I always say that I've never regretted putting a tube in someone, but I have many times regretted NOT putting a tube in someone. The backup is always GA and I don't feel like mucking around with an obese dude under the drapes because I wanted to see if he could fly with an epidural and a little bit of versed.
 
anes121508 said:
Would any of you guys trial him on Psv or extubate to bipap if all looked well?
Click to expand...

if a patient has a quick surgery and hasn't received a bunch of narcotics and I think they are close to their baseline pulmonary wise, I'm more than willing to pull the tube and see what happens (assuming it was easy to put in). That will require a kinda long PACU stay, though, because I'm not sending him out unless I'm fairly sure he's going to fly overnight.
 
anes121508 said:
Agree, high likelihood he needs vent post op....

But just just to play devils advocate, if you have no narcs on, epidural is working, fully reversed, case was quick, minimal fluids, abg is fine, intubation was smooth.....why not at least see how he does on psv? I guess the atelectasis from inhalational gas is there...but Is he going to be any better in 24 hrs snowed on the vent over night so the sicu nurses don't have to deal with him?

All I'm getting at is that many people get left intubated and sent to the sicu that could have been extubated in the OR...some of those end up with VAP, some of those get tons of benzos and more narcs for sedation and have illeus and post op delirium.....I'm not sure that being on a vent is Doing him any good

Would any of you guys trial him on Psv or extubate to bipap if all looked well?
Click to expand...

I'm pretty aggressive with giving a trial of extubation in the OR, but this patient has zero reserve. I see what you are getting at, though. His primary pulmonary problem is irreversible short of a lung transplant, so what is the point of keeping him intubated? I think you really need to make sure there aren't going to be any fluid shifts postoperatively, his pain is really well controlled, and he is WIDE awake. Given the minuscule margin for error and the fact that he is a possible difficult intubation, I would keep this guy tubed. He may never get extubated, but that possibility was already discussed at length with him and his family. There's also the high probability that this guy will end up getting intubated anyway even if you do some fancy neuraxial technique.

The more I think about this case, the more I think going through with it violates "First do no harm."
 
I agree with those who say that this patient will be dead by the time he develops colon cancer. What's his survival, with his current status? Maybe 10 years, optimistically? (I am curious what the exact PFT numbers were.) I would recommend a pulmonary consult for the patient (if he's not already followed by one - he needs optimization, home O2, and possibly therapeutic phlebotomy, unless he stops smoking). Long-term smoking cessation is a must, also for postop healing.

The airway is the least of the issues. Shave beard and/or or videolaryngoscope, prop, sux, tube. The problem is extubation and respiratory prognosis in a chronic lung patient after open abdominal surgery. He probably also has significant pulmonary HTN. Agree that laparoscopy in this guy could be a bad idea, if he has significant lung disease. Neuraxial anesthesia as main anesthetic, too, most likely, for both physiologic and psychological reasons, but he will need an epidural for post-op analgesia.

Anyway, this is elective surgery in an unoptimized patient and will not happen until the benefits exceed the risks. It will take months and a very motivated patient to get there.
 
Last edited by a moderator:
I don't know why so many of you are so eager to do CSE/sedation on a guy who can't lie supine and likely has moderate to severe pulmonary hypertension. This case is not urgent (or even necessary for that matter). But if you must, optimize his lung function (pulm consult, steroids, abx, duonebs for kicks) and get a RHC to see what PAP/PVR you're dealing with and whether it's responsive to dilators. If in a couple weeks you actually get him to the point where his breathing is comfortable and he's satting 90s on 2-4L NC, then you can proceed with placing an epidural, a-line, tube so you can precisely control this guy's paCO2 and actually deliver 100% Fi if needed, and do an opioid sparing technique. Extubate in the ICU to bipap.
 
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IlDestriero said:
And his polyp probably changed color because his pulmonary disease has progressed to include significant hypoxemia.
Click to expand...

LOL

Probably.

GI knows it's not cancer ... how? They biopsied it? I'm idly curious to hear how he did when they laid this guy flat and sedated him for his colonoscopy.

I wouldn't do this case. He needs to go home and quit smoking (of course he won't), and a pulmonologist needs to see about optimizing him (beyond some home O2 there's probably not much to do), and then the more appropriate surgical consult would be to transplant, not colorectal.

Or better yet, Hospice. Let the guy die with his cigarettes and some dignity, outside a hospital.
 
Wow, nice responses everyone. Let me address a few things off the top of my head.

FFP: you wanted to optimize this guy, right? How do you plan to do this? He had no improvement with bronchodilators during the PFT's. He won't stop smoking. He has no coronary issues that can be addressed. It will take many months for him to lose weight if at all.

Those of you that considering a CSE, at what level would you do this? This is an upper abdominal incision ( polyp in transverse colon). Your epidural will be ****. Poor plan IMO.

Those that want to do this under regional, how many of these cases have you done this way? Because if you haven't done quite a few then you are dreaming. Recipe for disaster. This is not the guy to experiment on.

Airway is the least of my worries in this case. Just had to state that one.

Anes121508, while your status says med stud, your responses say CA -1. Keep it up. You are thinking and that is good. But your focus needs some refining. Please take this as a compliment. Don't get caught up in all the details. Think about how you might get this guy through the case safely and then how you might help to make sure he leaves the hospital on his own two feet.
 
I do not place spinals in patients with severe pulmonary HTN. The abrupt hypotension can lead to acute right heart failure and precipitate the classic death spiral.

I would place isobaric marcaine for a hip, for example. But I stay away from the 0.75% / dextrose variety.

Anyone do spinals in folks with severe pulmonary HTN?


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